Iatrogenic bowel injury is a recognized complication of percutaneous suprapubic cystostomy. In the present report, we report an unusual case of small bowel perforation caused by a misplacement of suprapubic catheter into terminal ileum. For safe placement of a suprapubic catheter, the patients must have an adequately distended bladder and be placed in Trendelenburg position that allows safe extraperitoneal puncture of the bladder.
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